Hmo's And Other Health Plans example essay topic

Mark Miller ENG 101 December 2, 2000 HMO Regulation Health Maintenance Organizations, or HMO's, are a very important part of the American health care system. Also referred to as managed care programs, HMO's are combinations of doctors and insurance companies that are formed into one organization. This organization provides treatment to its members at fixed costs and decides on what treatment, if any, will be given based on the patient's or doctor's current health plan. Sometimes, no treatment is given at all. HMO's main concerns are to control costs and supposedly provide the best possible treatment to their patients.

But it seems to the naked eye that instead their main goal is to get more people enrolled so that they can maintain or raise current premiums paid by consumers using their service. For HMO's, profit comes first- not patients' lives. HMO's are groups of doctors hired by insurance companies and are usually controlled or regulated by the hospitals who facilitate them. The majority of this limitation is due to pressure from within the organization or government pressure. The government influences hospitals into denying treatment in order to cut federal costs. These government actions generally result in a revision of private employee health care claims, and in turn certain businesses can no longer afford to provide health insurance for their employees.

Consequently, approximately 50 to 60 million people go without insurance for at least one month each year. Many HMO's constantly evaluate their services to 'ensure' the best care and coverage. But in many cases, what is happening is the exact opposite. HMO's can and do conduct their business quite ruthlessly.

Patients are continuously unable to receive the necessary treatment due to the insufficient HMO coverage. Many HMO's actually make more money if their doctors see or treat fewer patients. According to the Associated Press, "Consumers who have been denied a treatment that the HMO says is not covered, or who inadvertently fail to follow HMO guidelines in seeking treatment and are therefore denied reimbursement, will continue to have little recourse". (2) Many people must drive for hours, generally sick or injured, simply to receive treatment from a doctor that will be covered by their HMO. Another downfall to HMO coverage is selective-contracting. This is a process where hospitals deny treatment to patients because their HMO is not on the hospital's provider list.

Doctors repeatedly turn away patients, even those with severe ailments, simply because if they were to treat them, then the cost for this treatment would come out of the physician's own pocket. Thomas Boden heimer said, "Selective contracting is common in managed care throughout the United States. It was created so that managed care could negotiate discount prices for physician, ancillary, and hospital services". (3) But in fact selective contracting is used only to restrict doctor availability and in turn raise profits for the HMO.

Control and implementation of forced regulations is another important issue. Many health care plans include gag clauses in their contracts with physicians. Gag clauses impose contractual limitations that interfere with physician-patient relationships. They include types of contract clauses that limit a physician's ability to advise patients of all medically appropriate treatment options. The extent to which these different types of clauses exist lie in current HMO contracts with physicians.

In 1996, the American Medical Association's Council on Ethical and Judicial Affairs stated that gag clauses were an unethical interference in the physician-patient relationship. Several states have taken action against these clauses in an effort to strengthen consumer protections in managed care programs. The federal government has also taken action against gag clauses by notifying HMO's and other health plans that they may restrict what physicians tell Medicare or Medicaid patients about treatment options. The United Health Group in New York is taking a different approach to providing health care. Milt Freudenheim and Jennifer Stein hauer said, "They return decision-making power over patient care to physicians on issues like admitting health plan members to hospitals or providing other treatments".

(12) This kind of decision is made to eliminate the frustrating features of most doctors' work: getting insurance companies to approve medical decisions that the doctors are more than qualified to make themselves. If all HMO's operated like this, then health care would go a lot smoother around the country. Instead of doctors worrying if the patients are covered or if a needed procedure is covered under a health plan, they can go ahead and perform what is necessary for the patient. Many people do not understand HMO's and that is why there are constant questions of why they should be regulated. People need to consult their health care providers and get a better understanding of what is provided and what is not, so later there is no confusion of what type of care they should have received.

Under most HMO plans, patients are no longer allowed to select their own doctor. Often times your doctor of choice is not a part of your HMO, so in order for your visit to be covered you must see a doctor that is a part of your HMO. Hospitals are the same way. If one particular hospital is not a part of your HMO, then your treatment would not be covered under your plan. No matter how far away the hospital is located that is a part of your HMO, in order to receive proper treatment and coverage, you must go there, not to the hospital located just down the street from your house.

Many HMO's could change their policies that would improve the services that they provide. One change could be to provide longer coverage for patients, which would secure faith between HMO's and their patients. Selective contracting should also be done away with. The only thing selective contracting does is raise profits for the HMO. The public receives no benefit from it. In fact, the public is only harmed by selective contracting.

Another thing that might help restore faith in HMO's is if they provided more resources to their patients. HMO's are notorious for not providing enough for their patients. Legislation should pass a bill that will benefit those who use HMO's and Medicare plans, because people who make monthly payments for service are usually punished by a raise in costs. According to Chip Kahn, President of the HIA A, from Richard Coorsh's article, "Legislation also contains new, unnecessary mandates that would raise costs for Medicare beneficiaries".

(1) Sometimes people pay premiums for 15 to 20 years and may never even use health care. This is extremely unfair because over time costs to the HMO's go up due to denied treatment and bad treatment, and consequently HMO's are forced to raise their costs to cover their mistakes. This is the exact opposite of what the country needs. Why should costs go up because of denied treatment? The big concern is whether or not government really understands the great difficulty in trying to control HMO's and other health care programs without a nationalized program. Since there are some 6 million people using Medicare in HMO's something needs to be done to ensure these patients the treatment that they need.

In conclusion, there still needs to be a lot of work done to health care in the United States. Other nations provide universal health care to their citizens, but this would cause dilemmas in balancing two often conflicting policy goals: providing the public with equitable access to needed pharmaceuticals while controlling the costs. Universal health care probably would not work in the U.S. because our nation is so diverse and our economy is so complex. The system we have now obviously has its problems, and there is a lot of rom for improvement.

HMO's will still create problems for people and their medical bills, but they definitely should be monitored to see that their patients are receiving just treatment.